Their solvency is preposterous. Their argument assumes that everyone who is at-risk of committing suicide or abusing drugs will access mental health care and that it will be effective.
Many barriers beyond affordability – stigma, clinician shortage, fragmented care
Sarah Heath, August 7, 2019, Key Barriers Limiting Patient Access to Mental Healthcare, https://patientengagementhit.com/news/key-barriers-limiting-patient-access-to-mental-healthcare
August 07, 2019 – Patients all across the country experience some sort of mental health issue every day. But instead of visiting the doctor like they might for a sprained ankle or chest pains, these individuals face considerable patient access barriers keeping them out of the mental healthcare setting. The National Alliance on Mental Illness (NAMI) reports that one-in-four individuals experiences a mental illness each year, underscoring a critical need for mental healthcare access across all patient populations. This is a pervasive issue that warrants the kind of attention other chronic diseases often receive. But access to mental healthcare isn’t exactly happening, as millions of Americans are going without access to care, per Mental Health America. That limited care access is not for lack of patient motivation. A 2018 survey from the National Council on Behavioral Health (NCBH) showed that 56 percent of patients want to access a mental healthcare provider, but many face care barriers. Limited health insurance access or in-network care are keeping many patients from visiting a mental healthcare professional. And even when a patient can find an affordable provider who will accept insurance, clinician shortages, fragmented care, and societal stigma are getting in the way of adequate care access. MENTAL HEALTH CLINICIAN SHORTAG One of the primary causes for limited mental healthcare access is logical – there simply are may not be enough qualified mental health professionals to meet demand. The nation is currently staring down a significant clinician shortage, and the mental health specialty is not immune to this. There are mental health professional shortage areas in every state across the United States, according to 2018 data from the Kaiser Family Foundation. The nation needs just over 7,000 more mental health clinicians to fill the provider shortage. Currently, only about one-quarter of the nation’s mental health provider needs are met, a figure KFF calculated by dividing the number of available psychiatrists by the number the US needs to have filled its clinician shortage. And, ultimately, this clinician shortage is making it hard for patients to access care. The NCBH survey revealed that 31 percent of patients faced a mental health appointment wait time longer than one week, which can have a severe impact on a patient who is in crisis Patients also have to travel long distances to visit a mental health clinician, with 46 percent of patients reporting that they or someone they know has had to travel more than an hour to access care in a timely manner. These travel distances can be prohibitive for patients, especially those who lack access to reliable transportation or the social supports that enable them to take time to travel to the doctor, such as childcare or paid time off from work. Industry professionals have proposed some solutions to these issues. Telehealth, for example, could be a viable option for filling an access gap, but only 7 percent of patients have tried it thus far, according to NCBH. Forty-five percent of those who have not used telehealth said they would be open to the possibility. However, telehealth does have its limitations, specifically in that it does not actually quell the mental health clinician shortage. A qualified psychiatrist or mental health counselor must be on the line for those telehealth consults. Telehealth presents an avenue to access for patients in particular mental health deserts. Instead, the industry must focus on recruiting enough mental health professionals to address the looming clinician shortage. LIMITED MENTAL HEALTH ACCESS PARIT Even when there is a mental health professional available, patients often face challenges identifying one who will accept their insurance. Narrow networks make it hard for patients to access mental healthcare at an affordable price. READ MORE: Payers, Purchasers Must Guarantee Mental Health Access Parity Data from a 2018 National Alliance of Healthcare Purchaser Coalitions report noted that mental health access is more difficult than physical health access because there are fewer in-network options for patients. Looking at eight common employer-sponsored health plans, researchers found that patients had to access out-of-network care for mental health 13 percent of the time. Patients only had to access out-of-network care for physical health 5 percent of the time, highlighting that patients have more in-network options for physical healthcare. What the researchers couldn’t ascertain was the number of patients who did not access mental healthcare at all because they had no in-network options. Out-of-network care is known for being exceptionally costly for the patient. If a patient can only access out-of-network providers, they may choose to go without care altogether. The NCBH survey confirms these findings, revealing that 42 percent of patients see high cost and limited insurance coverage as their main barriers to accessing mental healthcare. As patients face limited options for in-network mental healthcare, they either face large medical bills or are unable to visit a medical professional at all. FRAGMENTED MENTAL AND PHYSICAL HEALTH ACCESS Creating parity is not necessarily enough, many healthcare experts state. Organizations need to integrate their mental and physical healthcare offerings in order to ensure adequate care access, according to a 2018 paper in NEJM Catalyst. “In the US, historically we have separated out mental and behavioral illnesses from physical illness,” said Amy Compton-Phillips, MD, executive vice president and chief clinical officer for Providence St. Joseph Health and theme leader for NEJM Catalyst’s Care Redesign sector. “What we are learning – at a pretty high cost – is that having two separate and unequal systems of care results in suboptimal treatment of a patient.” Most organizations say they are falling short in offering mental healthcare to their patients, with just about half of providers saying their mental health offerings are inadequate. And although 77 percent say they have some sort of mental health offering within their clinics, most of them say this offering is not expansive and does not emphasize a holistic view of wellness. Overall, 33 percent of providers say care fragmentation is a barrier to sufficient mental healthcare access. Organizations should be wary of simply layering mental healthcare over primary care, or just offering the two services in tandem, Compton-Phillips and the paper authors noted. Instead, conducting a community health needs assessment will help uncover the issues that can impact care access that extend beyond the scope of the clinician office. Using primary care to address domestic violence issues could close the gap to mental healthcare access, for example. This strategy will require health data interoperability and information sharing between patient, primary care provider, and mental health specialist. However, a holistic approach to medicine will ideally break down the siloes that have so long separated care. SOCIAL STIGMA AND LIMITED MENTAL HEALTH AWARENESS Often, barriers to mental healthcare access are cultural, as patients feel the pressure of societal stigma and avoid visiting mental health professionals. Thirty-one percent of respondents in the NCBH survey said they wanted to access mental healthcare but were worried about what others would think of them. Twenty-one percent said they did end up accessing mental healthcare but lied about having visited a mental health clinic. Issues with social stigma varied among age brackets, the survey authors pointed out. Just under half of younger, Generation Z patients said they feared social stigma, compared to 40 percent of Millennial patients. Thirty percent of Generation X said they had concerns about stigma and mental health while 20 percent of Baby Boomers said the same. But social stigma is doing more than just keeping some patients away from the mental health clinic
; it is also obstructing societal awareness about mental health and making it more difficult to know about and navigate the healthcare industry. According to the NCBH survey, very few patients can actually navigate the mental healthcare space. Twenty-nine percent of respondents said they wanted to access mental healthcare for themselves or a loved one but did not because they did not know where to go. Twenty-one percent of respondents said they wanted to access mental healthcare but could not because of reasons outside of their control, although the survey did not detail what those reasons were. This trend is exacerbated among low-income patients. Compared to their middle- and high-income counterparts, low-income patients are less likely to know where to access mental healthcare and more likely to visit a community center for treatment rather than a specialized mental health clinic. Ultimately, it will take an industry culture shift to preserve patient access to mental healthcare. Through that shift, leaders can focus on creating coverage parity between physical and mental health and address the key limitations barring patients from accessing care.
The treatments fail, so it doesn’t matter if people can get them
Allen J Frances M.D., 2016, Psychology Today, What to Do When Treatment Doesn’t Work, https://www.psychologytoday.com/us/blog/saving-normal/201607/what-do-when-treatment-doesnt-work
Treatment of mental illness started from an almost non-existent base 200 years ago and perhaps it is not surprising that we still have so much left to learn. If we take the whole range of mental illness, from common disorders such as anxiety and depression, to severe disorders such as schizophrenia, and the hinterland of other conditions, such as personality disorder and intellectual disability, then approximately 50% of all patients with mental illness either have no satisfactory treatments available or often fail to respond to existing ones that may help others. What do we normally do about this in psychiatry? We use terms like treatment-resistance and treatment-refractory, but this is merely an admission of our failure to have a solution. The problem is that, in our therapeutically enthusiastic age, we do not admit failure as readily as we should. We persist in treatment, usually by giving whatever has failed previously in more dosage or by adding new treatments that have little chance of success, but a high risk of side effects. The sad conclusion, still denied by some, is that in the most severe mental illnesses, such as schizophrenia and the autistic group of disorders, we have made no real advances in treatment efficacy for 50 years What I call “nidotherapy” is a way of adapting optimally to this impasse. The term is derived from ‘nidus’ (the Latin name for nest). The idea is to undertake a collaborative and systematic manipulation of the person’s environment to make for a better fit to minimize the negative impact of untreatable mental illness on both the individual and others. article continues after advertisement
Mental health care is institutionally racist. Increasing access to it means more racism and more mental health problems
Medical News Today, July 3, 2020, https://www.medicalnewstoday.com/articles/racism-in-mental-healthcare-an-invisible-barrier, Racism in mental healthcare: An invisible barrier
Studies have shown that systemic racism often means that people of color and those belonging to other marginalized ethnic groups do not receive the mental health support they need. In this Special Feature, we explore the impact of racism as a public healthcare hazard in the mental health arena. In this Special Feature, we look at how racism impacts community-wide access to formal mental healthcare support.
Recently, Fiona Godlee — editor-in-chief at the BMJ — wrote a column in which she called racism “the other pandemic.” “Racism is suddenly and at last everyone’s business, and acting against it is everyone’s responsibility,” she points out. Action has been a long time coming. For years, studies from around the world have shown that systemic racism blocks access to healthful lifestyles and appropriate healthcare among consistently marginalized groups — particularly people of color. Despite this, decision makers have done little to address these inequities. In some of our recent features at Medical News Today — which are part of an ongoing series about race-related health disparities — we have discussed how and why the COVID-19 pandemic has disproportionately hit Black communities, and how the pandemic is likely to impact the mental health of people of color. Now, we look at how racism has forever been an obstacle blocking people’s access to appropriate formal mental healthcare among those in marginalized ethnic groups.We acknowledge that “people of color” is a very general term that encompasses numerous groups and identities, each of which has faced subtly different forms of racist discrimination. The same goes for the term marginalized ethnic groups. However, the aim of this feature is to provide an introduction to the impact of racism on mental healthcare. Future features will look at how racism has affected health and healthcare access in distinct marginalized groups more specifically. The impact of institutional racis Many forms of racism can be very subtle. Microaggressions, such as making assumptions about a person in conversation, often go unnoticed except by the person or people on the receiving end. In a personal essay called “On Becoming a Psychologist” — which appears in The Colour Of Madness, a book exploring the relationship between people of color and mental health — psychologist Cassie Addai wrote of experiencing such forms of aggression Growing up as a Black girl in a majority-white city, I can vividly recall examples of overt racism including being teased because of my ‘thick lips’ and being told to ‘go back/to where I ‘came from,’” she wrote. However, although people can identify and call out individual racist remarks more easily and spontaneously once victims and allies become acquainted with the forms it takes, this is more complicated in the case of institutional, or systemic, racism.A s Prof. Hannah Bradby, a sociologist at Uppsala University in Sweden, explains in a 2010 paper in Sociological Research Online: “The distinction between individual and institutional racism arose with the Black power movement in the U.S. when it was described as subtle and less identifiable compared with individual racism. ‘Respectable’ individuals can absolve themselves from blame for individually racist acts but nonetheless ‘support officials and institutions that perpetuate institutionally racist policies.’” Institutional racism upholds misconceptions and baseless assumptions about race and ethnicity, and it affects all official institutions, including those that offer mental healthcare. In the United Kingdom, for instance, a 2014 report — commissioned by the Lankelly Chase Foundation, Mind, the Afiya Trust, and the Centre for Mental Health — found that although Black people had lower rates of mental illness than other ethnic groups, they were “more likely to be diagnosed with severe mental illness and […] three to five times mor likely than any other group to be diagnosed and admitted to hospital for schizophrenia.” Rates of involuntary commission to psychiatric hospitals were also 2.2 times higher than the average for Black African individuals in the U.K., 4.2 times higher for Black Caribbean people, and 6.6 times higher for those who identified as “Black – other ethnicity.” At the same time, Black individuals were more likely than other community members to receive poor or downright harsh treatment in mental healthcare settings. ‘Circles of fear’ continue to be experienced by Black service users and communities in relation to mainstream mental health services,” the report notes. “Treatment is more likely to be harsher or coercive [for Black people] than that received by white service users and characterized by a lower uptake of primary care, therapeutic, and psychological interventions,” it continues. The same report notes that Black and other marginalized groups consistently found it difficult to access mental healthcare to begin with. ‘Serious, unconscionable disparities Similar situations occur in the United States and elsewhere in the world. “There are serious, unconscionable disparities in access to mental health for people of color in America,” said Nathan Greene, Psy.D., one of MNT‘s expert advisors. “African Americans, Latinx, and Asian Americans receive treatment of mental health challenges at 50–70% lower rates than white Americans in this country. This is the result of failures on individual and systemic levels,” he added. A 2019 study in the journal Health Services Research looked at the data of 1,237 Black adults in the U.S. who reported not having received formal support for a mental health issue for which they required support. The data in this study came from the 2011–2015 National Survey on Drug Use and Health. Its author, Sirry Alang, Ph.D., found that Black individuals reported mistrust in mental health service systems due to experiences of racism. Black respondents — particularly those who had been through higher education — reported that they had experienced stigmatization, and that professionals had minimized their mental health symptoms. This resulted in a lack of access to appropriate care. On May 29, 2020, Daniel H. Gillison, Jr. — the CEO of the National Alliance on Mental Illness — released an official statement acknowledging the extent of mental healthcare disparities in communities of color in the U.S. “The effect of racism and racial trauma on mental health is real and cannot be ignored,” he said. “The disparity in access to mental healthcare in communities of color cannot be ignored. The inequality and lack of cultural competency in mental health treatment cannot be ignored.” Stigmatization and cultural barrier The stigmatization of mental health issues can further amplify the effect of institutional racism on access to healthcare among Black people and other marginalized communities. It is also true that institutional racism can amplify internalized stigma. In an article for Columbia University, psychologist Thomas Vance, Ph.D., writes about the relationship between institutional racism and the stigmatization of mental health issues, particularly in the context of Black communities. “The lack of cultural responsiveness from the therapist, cultural mistrust, and potential negative views from the therapist associated with stigma impact the provision of mental health services in the Black community,” Vance points out. Speaking to MNT, psychologist Riya Patel, Ph.D.* — an assistant professor in the Faculty Research Centre for Intelligent Healthcare at the University of Coventry in the U.K. — further explained the role of stigma associated with mental health issues among communities of color and marginalized ethnic groups. “The first important [barrier in accessing mental healthcare] relates to how mental health problems are experienced, shared, and supported within diverse minority communities,” she told us. “Shame and stigma about poor mental health are common across societies, but these experiences may be amplified in some cultural settings and hold people back from reaching out for assistance,” she added. However, cultural differences can also be barriers, Patel noted. Mental health professionals who do not understand patterns of communication characteristic of certain cultural groups may not understand the issue or prov
ide appropriate support. “People from different backgrounds experience and describe symptoms of mental ill health in different ways, which do not always fit prevailing models of mental healthcare.” – Riya Patel, Ph.D. She added, “People have options within their own communities for getting help and may not perceive a need to access formal services.” “If people experience systemic discrimination when they do use mainstream services, this can cause secondary victimization, exacerbate their mental health status, and lead to distrust between community members and health providers,” Patel noted.
Minority youth will not want mental health treatment. Those that do often end up in the criminal justice system
Rebecca Klisz-Hulbert is assistant professor in psychiatry and behavioral neurosciences at Wayne State University, August 15, 2020, Washington Post, Fewer Black teens seek treatment for depression, mental health issues than White counterparts, https://www.washingtonpost.com/health/black-youth-at-higher-risk-of-depression-mental-health-problems/2020/08/14/e28056ec-d66e-11ea-aff6-220dd3a14741_story.html?hpid=hp_national-right-4-0_hse-latest-feed%3Ahomepage%2Fstory-ans
Black youth in the U.S. experience more illness, poverty, and discrimination than their White counterparts. These issues put them at higher risk for depression and other mental health problems. Yet Black youth are less likely to seek treatment. About 9 percent of them reported an episode of major depression in the past year, but less than half of those — about 40 percent — received treatment. By comparison, about 46 percent of White youth who reported an episode were treated for depressive symptoms. nstead, some turn to suicide, now the second leading cause of death among Black children ages 10 to 19. That rate is rising faster for them than any other racial or ethnic group. Data from the Centers for Disease Control and Prevention show the rate of suicide attempts for Black adolescents rose 73 percent from 1991 to 2017. With schools nationwide grappling with how to offer instruction to students, principals and teachers need to be reminded that Black children have endured a distinctive kind of trauma since the pandemic began. They have had a different experience. The killings of George Floyd and Ahmaud Arbery — and what happened afterward — are just two examples. As an expert in child and adolescent psychology, I know that a multitude of barriers keep Black children, and their families, from receiving that treatment. They need help to deal with the pervasive poverty and racism that surrounds them. Studies suggest Black youth and their families may be less likely to identify their own mental health symptoms. If they do receive referrals for care, they may follow up less often than Whites. Delays in seeking care can lead to negative consequences, including emergency psychiatric hospitalizations and noncompliance with treatment recommendations. These youngsters may then become adults with mental health issues that remain unaddressed. Parents and caregivers should encourage treatment. But interviews with them done as part of one study revealed they sometimes obstruct the process. Many feared their child would be labeled “crazy.” Those caregivers, sensitive to social stigma, also relied on others in the community when deciding to pursue treatment for their sons. Sometimes they would receive support from those they spoke with; other times, they would not. Because of discrimination and abuse, Blacks have good reason to distrust the mental health system. Health-care disparities exist there just as they do in other health-care domains. Black adolescents are less likely than White teens to be treated with beneficial psychiatric medications, and more likely than White teens to be hospitalized involuntarily. Other reports suggest Black youth with psychiatric disorders are more likely to be referred to the juvenile justice system, while White youth are more often referred for mental health treatment.
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